Original Research Article DOI: 10.18231/2394-2126.2017.0004 Analysis of the vascular pattern in the superficial palmar arch formation Betty Anna Jose1,*, Shashi Rekha M.2, Surendra Babu T.3 1Associate Professor, 2Professor, 3Tutor, Dept. of Anatomy, Vydehi Institute of Medical Sciences & Research Centre, Bangalore, Karnataka *Corresponding Author: Email: [email protected] Abstract Background: The superficial palmar arch (SPA) is the main source of arterial supply to the palm. It is an arterial arcade formed mainly by the ulnar artery and is completed by the superficial palmar branch of the radial artery or princeps pollicis artery or radialis indicis artery or median artery. The knowledge about the variations in the formation of SPA is important in reconstructive hand surgery and in radial artery grafts. Objective: The objective of the present study is to identify the arterial patterns in the formation of superficial palmar arch and classify according to its formative tributaries. Material and Methods: The study conducted on 69 formalin fixed hands at Vydehi Institute of Medical Sciences and Research Centre, Bangalore. The vascular pattern of superficial palmar arch was recorded and classified according to the variations. Results: It was found that 96% of SPA were complete and 4% incomplete. Based on Coleman and Anson classification, type A arch was identified in 39%, type B in 17%, type C in 9%, type E in 31% and type G in 4%. Another finding was in 35% cases, the ulnar artery was highly tortuous in its course in the palm. A thin collateral or additional branch was found in 31% of the SPA. Conclusion: These findings on the variations of SPA is essential in microvascular surgery and radial artery harvesting in coronary artery bypass graft procedure. Keywords: Superficial Palmar Arch, Radial Artery, Ulnar Artery, Median Artery. Introduction adipose tissue was removed to view the superficial The knowledge about the variations in the vascular palmar arch and its branches. pattern in different parts of the body is very much The images of the dissected hands were captured. important in the field of micro vascular surgery for The superficial palmar arches were studied, and the revascularization and tissue transplantation. One such variations found were compared with previous studies. variation with clinical and surgical implication is the arterial supply of hand. The main arterial supply of hand Results is by the superficial palmar arch formed by the branches Among the 69 hands, the complete arch (Fig. 1) was of radial artery and ulnar artery. The radial artery is observed in 66 hands (96%) and incomplete arch in 4% widely selected as an arterial bypass conduit in coronary hands with right laterality. The right hands showed 36% artery bypass graft procedure. If the ulnar artery or of the complete arch and the remaining 64% were seen persistent median artery is sufficient for the proper in left sided hands. The SPA were further divided into arterial supply in hand, the radial artery is a non-essential different types according to the Coleman and Anson vessel and can be used in grafting. But if these two classification. The type A arch or the classical radio ulnar arteries are not compensating the supply of radial artery, arch was identified in 39%, type B formed entirely by its harvesting can induce a risk by resulting ischemia of ulnar artery in 17%, type C the mediano-ulnar arch in the soft tissues in hand.(1) 9%, type E (Fig. 2) where ulnar artery anastomose with The objective of the present study is to identify the a branch from the deep arch in 31% and type G in 4%. variations in the formation of superficial palmar arch In type G, which is an incomplete arch only ulnar artery (SPA) and classify according to the formative tributaries. was involved without supplying to thumb and index finger. The variations were found more commonly at the Materials and Methods radial side of the SPA. A total number of 69 adult hands, 27 right and 52 left ones, from embalmed human cadavers, used for routine dissection by undergraduate medical students, fixed in 10% formaldehyde solution were dissected. Two horizontal incisions were made, one at the wrist joint and another incision along the root of fingers. A vertical incision was made from the middle of the wrist to the 3rd metacarpophalangeal joint. The skin of the palm and the palmar aponeurosis was reflected. The surrounding Indian Journal of Clinical Anatomy and Physiology, January-March, 2017;4(1):11-15 11 Betty Anna Jose et al. Analysis of the vascular pattern in the superficial palmar arch formation Fig. 1: Shows complete arch by the radial and ulnar Fig. 3: Shows H-shaped Superficial palmar arch arteries Discussion Another finding was that, in 35% case, the ulnar The SPA is an arterial arcade between radial and artery was highly tortuous (Fig. 2) in its course in the ulnar arteries located in the palm, deep to the palmar palm. A thin collateral or additional branch (Fig. 2) was aponeurosis and superficial to the flexor tendons. It is found in 31% of the SPA. Among the arches with formed mainly by the ulnar artery. At the other end, the supplementary branch, 50% of the hands showed arch is completed normally by anastomosing with the tortousity in the ulnar artery. In 9 hands, additional superficial branch of radial artery. In other subjects, the branch was observed, without any tortousity in the ulnar ulnar artery is anastomosing with the arteria radialis artery. The chi-square test did not show any significant indicis, or princeps pollicis artery. Occasionally the ulnar association between additional branch in the SPA and artery anastomose with the arteria nervi mediana. In tortuous ulnar artery (p>0.05). about one third of the subjects, the arch is formed only by the ulnar artery.(2) This indicates the possible variations in SPA formation. So it is always interesting to note that which is the most commonly observed variation in each study, as it varies according to race.(3) Many studies have been conducted to classify the variations in SPA. There are different classifications put forth in literature based on the formative vessels and its size. The most commonly used classifications are by Gelman et al,(4) Adachi,(5) Huber(6) and Coleman and Anson.(7) Gelman et al(4) classified the SPA into complete or incomplete arch. If an anatomosis is present between the formative tributaries of the arch, it is considered as a complete one and in incomplete one such anastomosis is Fig. 2: Shows type E superficial palmar arch absent. The present study showed 96% complete arches and 4% incomplete arches. Our study showed a similar (8) One hand showed radio-ulnar type of SPA with result of the study by Ikeda et al. The presence of equal contribution from both the arteries and two arteries complete arch varies from 45% to 96.4% in different are connected by a communicating branch which gives population as showed in Table 1. In a study by Nasar et (9) an H-shaped appearance as shown in Fig. 3. The ulnar al. 91.39% complete classical arch, 4.35% ulnar type (10) artery showed comparatively larger diameter than its and in 4.45% SPA was absent. Patnaik et al. found counterpart in 60 hands (87%). The radial and ulnar double SPA in 6% of hands. The remaining 94% were arteries were equal sized in 6 hands (9%) and larger single SPA with 78% complete arches and 16% radial artery was found in 3 hands (4%). These 9 hands incomplete arches. The current study is in accordance (11) showed classical radio-ulnar SPA or type A arches. with the result of study by Vidya et al. and Suma et al.(12) The Indian studies showed high percentage of complete arches when compared to the other populations(Table 1). Indian Journal of Clinical Anatomy and Physiology, January-March, 2017;4(1):11-15 12 Betty Anna Jose et al. Analysis of the vascular pattern in the superficial palmar arch formation Table 1: Showing the distribution of complete and incomplete arches in various studies Study Country Sample SPA type in percentage size Complete Incomplete arch arch Coleman(7) USA 650 78.5 21.5 Ikeda(8) Japan 220 96.4 3.6 Al-Turk(13) USA 50 84 16 Loukas(3) USA 200 78 16 Fazan(14) Brazil 46 48 52 Bilge(15) Turkey 50 86 14 Sarkar(16) Singapore 42 45 55 Patnaik(10) India 50 78 16 Vidya(11) India 50 92 8 Suma(12) India 20 95 5 Joshi(17) India 100 82 18 Present India 69 96 4 According to Adachi, there are 3 types of SPA. Type ulnar artery and superficial branch of radial artery takes I or ulnar arch, has minimal or no contribution from the part without anastomose, Type G only ulnar artery is radial artery. Type II or radio-ulnar arch has contribution involved but not supplying the thumb or index finger. from radial and ulnar arteries and type III or median- Type H is the median-ulnar type without anatomosis and ulnar in which median artery is replacing the radial in type I, the radial, median and ulnar arteries give origin artery.(5) The current study identified 17% type I, 39% to superficial vessels without anastomosis.(7,12) type II and 9% type III superficial palmar arches. As per this Coleman and Anson classification, our Huber explained two types of arches. In type 1, study showed 39% type A arch or the classical radio additional branches from forearm participate in SPA or ulnar arch, type B in 17%, type C in 9%, type E in 31% it replaces the radial artery.